Results from the Multicentre Randomized Arterial Revascularization Therapy Study

V. Legrand¹ MD, PhD, FESC,
P. Serruys² MD, PhD, FACC, FESC,
WK Lindeboom³ PhD,
M. Vrolix⁴ MD,
G. Fransen⁴ MD,
P. Materne⁵ MD,
G. Dekoster⁵ MD,
R. Seabra-Gomes⁶ MD,FESC,
J. Queiroz E Melo⁶ MD

¹CHU Liege Belgium.
²Thoraxcenter, Rotterdam, The Netherlands.
³Cardialysis, Rotterdam, The Netherlands.
⁴St Jansziekenhuis, Genk, Belgium.
⁵CHR Citadelle, Liege, Belgium.
⁶Hosp Santa Cruz, Carnaxide, Portugal.

Key words : coronary angioplasty, stent, coronary bypass surgery, elderly.

Introduction
As the population ages, an increasing number of elderly patients are presenting with symptomatic multivessel coronary artery disease requiring revascularization. However, the most appropriate myocardial revascularization procedure for older patients with multivessel disease is still controversial. Indeed, it is well recognized that the procedure-related morbidity associated with either percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) increases dramatically with age.

Paul B. Miller, BA, MA, MPhil, is a JD/PhD candidate in law and philosophy at the University of Toronto, and a Junior Fellow of Massey College in Toronto, Toronto, ON.
Trudo Lemmens, Lic Iur, LLM, is Assistant Professor in the Faculty of Law at the University of Toronto, Toronto, ON.

Lucrative Research
A pharmaceutical company invites Dr. B, a primary care physician, to assist with a placebo-controlled randomized clinical trial (RCT) of a new cholinesterase inhibitor for the treatment of dementia. The study will include patients who have been diagnosed with early-onset dementia. Dr B will receive $3,500 for each patient who ultimately agrees to enrol in the study. In the protocol, this fee is explained as payment of the administrative costs associated with Dr B's participation in the trial (in particular, as payment of "costs of obtaining informed consent, accumulating data, secretarial support, and consultation with each subject").

This hypothetical case illustrates an increasingly common phenomenon--offers of "finder's fees" and other "administrative" fees by pharmaceutical companies or Contract Research Organizations (CROs) to primary care physicians for conducting research involving their patients. Finder's fees are offers of money to physicians in reward for referral of patients eligible for research participation. They can be distinguished from payments made to cover costs of research participation.

Jerilynn C. Prior MD, FRCPC, Professor of Endocrinology/Metabolism, Department of Medicine, University of British Columbia and Vancouver Hospital, Vancouver,

Abstract
Estrogen and progesterone (so-called "hormone replacement") therapy was formerly considered essential for menopausal women. The purpose of this paper is to outline the shifts in concepts related to estrogen and progesterone therapy and to describe situations in which it remains a practical, effective therapy for older women.

Estrogen and progesterone are useful for women >65 years old who have osteoporosis diagnosed by bone mineral density or vasomotor symptoms (VMS) disturbing sleep, especially if either are combined with recurrent urinary tract infections or severe dysparunia. If a woman has had a fragility fracture (in a fall from a standing height or less), hormone therapy should be combined with a bisphosphonate such as etidronate for optimal fracture prevention.

Optimal hormone therapy for older women, ideally, is transdermal (patch or gel), rather than oral, to decrease thromboembolic risks. Several lines of evidence suggest that low estrogen doses (such as 25 µg Estraderm®‚ patch, one pump Estragel®) are adequate. Oral micronized progesterone (Prometrium®), given daily, avoids flow, is effective for VMS and increases bone formation. Optimal therapy is daily full or moderate dose progesterone (200 to 300 mg or 5-10 mg medroxyprogesterone).

Dr. Clarfield is the Chief of Geriatrics, Soroka Hospital Centre, Professor, Faculty of Medicine, Ben Gurion University of the Negev, Beersheva, Israel. Professor (Adjunct), Division of Geriatric Medicine, McGill University and Jewish General Hospital, Montreal, QC, Canada.

Have you ever heard of the wonderful one-hoss shay.
That was built in such a logical way.
It ran a hundred years to a day.
And then, of a sudden, it-ah, but stay.
I'll tell you what happened without delay.
Scaring the parson into fits.
Frightening people out of their wits,
Have you ever heard of that, I say?
Oliver Wendell Holmes

My own grandfather died when he was over 100 years old. Why? We don't know because, for religious reasons, no autopsy was performed. Even if it had been, what might it have shown? Possibly a Whitmore stage A or B carcinoma of the prostate, maybe a tumour in the cecum, perhaps the scars of previous myocardial infarcts, but very likely nothing that a pathologist could confidently have labeled as the cause of death.

So why do old people die? Is aging a disease or is it simply a normal life stage? Or, as Crapo and Fries have so elegantly described in their book "Vitality and Aging" (from which the above quote was lifted), is it simply the final disintegration of the old buggy?

In order to come to some understanding as to what aging actually comprises, it might be helpful to examine what pertains in other mammalian species.

Dr. Gabriel Chan, MBBS(HK), FHKAM, MRCP(UK), ABIM, FRCP(C), FRCP(EDIN),
Director of Geriatric Medical Services and Program Medical Director of Long-Term Care, North York General Hospital, Lecturer of Medicine, University of Toronto, Toronto, ON.

Frances Simone, BSc, MHA, Director, Geriatric Ambulatory Care Services, North York General Hospital, Toronto, ON.

The POWER (Promoting Osteoporosis Wellness through Education, Exercise and Resources) program is a collaborative, multi-site initiative designed to empower older adults with osteoporosis to improve their quality of life and prevent falls. POWER consists of a seven-week, culturally sensitive education, exercise and nutrition program developed by North York General Hospital, Baycrest Centre for Geriatric Care, Toronto Public Health and Yee Hong Centre for Geriatric Care. POWER is an effective health promotion model for osteoporosis management and falls prevention that can be replicated in other communities across the country.

Health promotion and disease prevention are very important concepts that support our collective goal for a healthy society. Currently, there is a need to develop models that fully integrate health promotion activities into our 'illness treatment' oriented health system. Without such models, we will face significant challenges as our population ages and our health system attempts to cope with the impact of chronic diseases.

Kathryn M. Yorkston, Ph.D., BC-NCD, Department of Rehabilitation Medicine, University of Washington, Seattle, WA.
David Beukelman, Ph.D., Department of Special Education and Communication Disorders, University of Nebraska, Lincoln, Munroe-Meyer Institute for Genetics and Rehabilitation, University of Nebraska, Omaha, NE.
Laura Ball, Ph.D., Munroe-Meyer Institute for Genetics and Rehabilitation, University of Nebraska, Omaha, NE.

Summary
This article describes intervention for dysarthria associated with amyotrophic lateral sclerosis (ALS). Five critical periods are presented including a stage with normal speech, detectable speech disturbance, behavioural intervention, use of augmentative communication, and loss of useful speech. Intervention strategies at each of these stages are outlined with the goal of maintaining functional communication regardless of the severity of dysarthria.

ALS is a rapidly progressive degenerative disease of unknown etiology involving the motor neurons of both the brain and spinal cord.¹ The symptoms characteristic of ALS are generally classified by site of involvement (that is, upper motor neuron versus lower motor neuron) and by whether spinal nerves (those innervating the arms and legs) or bulbar nerves (those innervating the muscles of speech and swallowing) are involved.

Levent Ozdal, MD, Research Fellow, Department of Urology, McGill University, Montreal, QC.
Simon Tanguay, MD, FRCS(C), Associate Professor, Department of Urology, McGill University, Montreal, QC.

Benign prostate hyperplasia (BPH) is the most common benign neoplasm in aging men. Although microscopic evidence of BPH occurs in 80% of men who are at least 80 years old, clinical enlargement of the gland only occurs in half of all men in this age group. Furthermore, symptomatic disease only develops in about half of men with clinically enlarged prostate glands.¹

Lower urinary tract symptoms (LUTS) of BPH can be obstructive or irritative in nature. Most symptoms occur and progress slowly in aging men. The treatment of BPH is usually indicated once patients develop either moderate or severe symptoms, or in the presence of complications due to bladder obstruction. Complications of BPH due to chronic obstruction include recurrent urinary tract infection, bladder stones, incontinence, gross hematuria, urinary retention or renal failure.

The aim of BPH treatment should include improving or eradicating symptoms, reversing the complications of the disease and preventing additional sequelae. Treatment is typically based on the severity of symptoms and patient preference.

Karl Farcnik, BSc, MD, FRCPC, Psychiatrist, Division of Geriatric Psychiatry, University of Toronto, Toronto, ON.
Michelle Persyko, Psy.D, C.Psych, University of Toronto, Toronto, ON.
C. Bassel, M.A., University of Toronto, Toronto, ON.

Introduction
Aphasia has been described as a disorder of verbal communication due to an acquired lesion (or lesions) of the central nervous system involving speech production and/or comprehension.¹ Aphasia does not involve deficits in global processes of communication, but only in its linguistic component, as evidenced by patients' ability to communicate through other means (e.g., complex nonverbal gestures).² Aphasia is an integral part of the clinical presentation in Alzheimer Disease (AD). It is also an important diagnostic feature of other neurological disorders, which may be distinctive or overlap with AD. Clinicians should have a conceptual understanding of the different forms of aphasia as well as the conditions with which they are associated. The authors will review the diagnosis, assessment and treatment of aphasia, in the context of AD, Primary Progressive Aphasia (PPA), Frontotemporal dementia (FTD) and stroke.

The major types of aphasia can be classified as either fluent or nonfluent.

Anne-Sophie Rigaud, Hôpital Broca, CHU Cochin-Port-Royal, Paris, France.
Bernard Forette, Centre Claude Bernard de Gérontologie, Hôpital Sainte Périne, Paris, France.

Abstract
Diastolic blood pressure is considered an important risk factor for the development of cerebrovascular disease, congestive heart failure and coronary heart disease. However, it is now clear that isolated systolic hypertension and elevated pulse pressure play an important role in the development of these diseases, which are the major causes of cardiovascular morbidity and mortality among subjects aged 65 years and older. The benefit of antihypertensive therapy in reducing the incidence of cardiovascular and cerebrovascular complications has been shown for systolic and systolo-diastolic hypertension in all age groups. Because of the higher risk of cardiovascular disease in the elderly, the effect of antihypertensive treatment appears greater in patients over 60 or 65 years when expressed as an absolute risk reduction.

Definition
Essential (i.e. primary) hypertension is the main cause of hypertension in the elderly population. However, secondary, especially renovascular hypertension is more common in older than in younger adults. The incidence of hypertension in the elderly is high. In an ambulatory population aged 65-74, the overall prevalence is 49.6 % for stage 1 hypertension (140-159/90-99 mmHg), 18.2% for stage 2 (160-179/100-109 mmHg), and 6.

D'Arcy Little, MD, CCFP, Director of Medical Education, York Community Services, Toronto and Academic Fellow, Department of Family and Community Medicine, University of Toronto, Toronto, ON.

Introduction/Epidemiology
Osteoporosis is a common, serious disease in older adults. Until recently, osteoporosis research and treatment have focussed on postmenopausal women. Recently, however, the epidemiology of this condition in elderly men has become clearer and it is evident that osteoporosis is also prevalent in this population. In fact, men over the age of 50 years have a 19-25% lifetime risk of an osteoporotic fracture, as compared to women who have a 50% lifetime risk. In addition, it is estimated that 30% of hip fractures that occur worldwide occur in men, and lead to significant mortality and loss of independence. Indeed, post-hip fracture, men have a higher mortality rate than do women.^1,2,3,4 The role of androgens in bone physiology has suggested that testosterone may be one arm in the treatment regimen. The following article will review the place of testosterone in the management of osteoporosis in males.

Bone Physiology and Pathophysiology
Osteoporosis is a "disease characterized by low bone mass and microarchitectural deterioration of bone tissue leading to enhanced bone fragility and a consequent increase in fracture incidence."⁵ The origin of idiopathic osteoporosis lies in the aging process and normal bone physiology.